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Based on medical record review, policy review, and staff interview, the hospital failed to ensure a registered nurse supervised nursing care for one of ten patient medical records reviewed who had fall precautions (Patient #1).

Findings include:

Review of the policy titled, Fall Prevention Program, effective 04/23/2020 and last reviewed 05/06/2020, revealed the Morse Fall Risk Scale should be completed on admission, on any transfer to another unit within the hospital, following any change in status, following a fall, weekly at minimum. Totaled scores greater than 45 indicates a risk of falling at a basic level. Additional assessment information will be used to determine high level. Interventions for basic risk levels included bed alarm level/zone 1, chair alarm, self releasing seatbelts, wheel chair positioning aids, toilet before leaving in room alone, toilet patient before giving high risk fall medications, diversional activities. Interventions for high risk levels included any of the basic level interventions, bed alarm level/zone 2, bed alarm level/zone 3, low bed, supervision in bathroom (stay with me), supervision at all times, 1:1 handoff, bedside perimeter mats, toileting schedule, pharmacy medication review.

Review of the medical record for Patient #1 revealed he/she was admitted to the facility on 05/13/2020. Fall precautions ordered on 05/13/2020 included self releasing seat belts, chair alarm, toliet before leaving room, three bed rails up when patient is in bed, diversional activities, bed alarm, low bed, and supervision in the bathroom. The history and physical by the physician on 05/14/2020 described the patient as at risk for falls and with general weakness. Review of the Morse Fall Risk screening completed on 05/14/2020 revealed the patient had a score of 70. The patient's Morse Fall Risk screening completed on 05/18/2020 revealed the patient had a score of 70.

The medical record revealed on 05/26/2020 at 1:05 PM. that Patient #1 had an unwitnessed fall in the bathroom. Patient #1's husband was in the room at the time of the fall.

Interview with Staff I on 06/02/20 at 10:44 AM revealed on 05/26/2020 Patient #1's call light was on. Staff I answered the call light and Patient #1 requested to go to the bathroom. Staff I assisted the patient to the bathroom by wheelchair and transferred Patient #1 to the toilet. Staff I then stood outside the patient's bathroom door. Staff I staff I stated he/she checked on the patient three times and the third time the patient was on the floor. Staff I called the registered nurse for help. There were no injuries noted.

Staff A was made aware of the findings on 06/04/2020 at 12:00 PM.